Friday, January 29, 2010


The guy is almost fifty, skinny and white, tatted up w/ Buddhas and Asian letters and all in all has the general affect of an angry teenage hipster.  He’s squirming and whining, and I’ll be honest, truly irritating the shit outta me and my partner. There’s a younger Asian girl there that he’s bossing around and that’s grating me even more. Also: there’s nothing apparently wrong with him. His pressure’s 158/90 his pulse is 70, he’s breathing regular, has no chest pain, no signs of trauma, hasn’t been pissing blood or puking excessively. Nothing.  That much is fine, we get patients w/ nothing wrong with em all the time. But this dude won’t sit up. Then when he does he’s slouched over so we can’t get the EKG on him properly. Then he wants to put his feet up even tho he’s in a chair and clearly can’t.
We being calm, mind you. The curseout I had waiting in the wings remained lodged in the back of my throat, even when the guy decides to lay down on the floor and starts grabbing my partner’s arm and screaming “Why won’t you give my something for my legs!? My legs are tingly! I don’t understand why you won’t help me!”
I was sharp w/ him, as I pried his hand from Mr. C, but I kept it basically cool. We lift him up, put him on our chair and cart him out. The Asian chick looks anxiously after us but doesn’t come with.
Ok. Reassessing as we wait for the elevator: he has no medical problems, no allergies, takes no meds. Has no complaint of pain beyond his legs feeling funny, but he clearly feels it when we pinch him to make sure there’s no nerve damage. He’s moaning still. When we told him we don’t give anything for funny leg feelings he apparently ignored us, cause he’s still asking for something. He denies any drug use, not sure if I believe him or not, but he’s alert, oriented to where and who he is, knows his birthday, etc and his pupils are normal.
Something happens between the elevator and the ambulance. It’s a subtle thing, very hard to describe if you’ve never seen it, but at some point, a small change in his body motion sets off little alarms in me. I can tell Mr. C sees it too, the way he eyeing the patient and then looking back at me. The guy’s still talking but his motion is more sporadic. His arms just flop loosely up in the air every couple seconds like he’s a marionette being jerked around by some sadistic puppeteer.
When we lift him from chair to stretcher there’s no question something’s wrong. He has enough energy to grab my arm and make it more difficult to move him, but that’s about it. And he’s talking less. When people who won’t shut up suddenly shut up you need to pay attention- (unlike the non-asthma attack having lady who was so busy cursing us out we couldn’t listen to her lungs, but we didn’t have2 anyway, cuz if you can curse us out w/out taking a breath for five min straight you aint having an asthma attack…)
At this point, I’m thinking hemorrhagic stroke and I’ll tell you why: The typical stroke, the one they tell you about in all those PSAs with the droopy one side of your face and slurred speech and can’t raise one hand- that presentation is more commonly for what’s called an ischemic stroke . Basically, a bloodclot is cutting off flow to one part of the brain, much like the way a heart attack works. But when the blood vessel bursts, either from trauma or high pressure or whathaveyou, its called a hemorrhagic stroke and you’re head fills up with fluid, increasing your intcranial pressure sometimes to the point that the brain tries to escape through the hole at the bottom of your skull. These kinda strokes don’t often look like the other kind: the pressure doesn’t neccesarily go as high until later on, there isn’t always one sided weakness and one thing I’ve noticed time and again with these, the patient won’t slur their speech so much as speak in tongues. It’s like the way a baby will talk utter gibberish but with total conviction, and they look like they think they really saying something that makes sense, but they just saying “Blarga blarga blorp blaa! Blarg! Blegh!”  and so on. And they get irritable.  Now this isn’t all that different from the way certain people look when they drunk or hopped up on some bullshit, mind you, and so it’s easy to miss. (Diabetics when their sugar drops tend to moan more and are usually sweaty and cool to the touch.) The only difference is that certain something, a kind of lethargy that takes over that is really a grim late sign- the body is giving up.
When we load him into the ambulance he’s pale as shit, still mumbling and squirming but looking otherwise very corpselike.  I take a blood pressure while Mr C drops a line. Well- I try- but there’s nothing to hear.  A very late sign. The last thing I notice before I slam the back doors closed is his respirtations- his body can’t be troubled to open his mouth any more, so they come out in a rude snoring kind of way, all spittely and loud.
I jump in the front, let the hospital know we comin and blast off down Dekalb. When I open the back in the ER bay Mr C says: How fast can you set up my tube? And indeed, I see the patient has stopped breathing. His heart rate has dropped down to 40. I jump in the back, pull out the tube kit, throw him the laryngescope, which he uses to hold open the guy’s jaw and get a look at those vocal cords. I screw the syringe onto the little attachment on the tube and pass that over as the heart rate dips down to 20.
“Uh…tube quick he’s checking out.”
But Mr. C is no fucking joke with a tube, before I can count to 10 he’s slid the thing in, confirmed it with the stethoscope and I’m passing him the platic device that holds it in place.  The heartrate slides back up to 50, then 70. “Ok, we straight,” he says, but then the lines on the EKG go all squiggly. “He’s in V-fib,” I say, going for the pads and thinking if this dude takes one more damn turn for the worse… Before I get a chance to put the pads on the rhythm straightens out back to 50 and then starts dropping.
We load him out the bus and hustle him into the ER, yelling out the presentation to the docs as we go.  His heart’s at 20 when we wheel him in and stops completely as we reach the crash room, where they work him up for another half hour before pronouncing him dead.
Ok, a couple things w/ this job:
It startled the shit outta me.  I’ll be honest- it didn’t really bother me so much as it just caught us off guard. In the end we moved with what happened, didn’t get caught up in the tunnel vision and what it started out as vs what it became. It was definitely a solid reminder to stay flexible: even when something looks, smells and sounds in every way like a basic bs anxiety attack, some real shit can be lurking.
Was there anything we could’ve done to stop what happened? Nope not at all. What this dude had going on was beyond anyone’s capacity to stop. He didn’t show any hints to what might’ve been going on before he started crashing and once he did it was waaaay to late to stop. Plus, we have nothing with us that would’ve stopped it.
Sometime I’ll blog about dealing with death on this job, but that’s for another day.

Saturday, January 2, 2010


Some jobs you walk in and know exactly whats goinon and what’s gonna happen next and all the things you’re gonna haveta do etc etc. You can see the whole thing wind out in front of you like a damn roadmap, and you quickly fall into the rhythm and BAM it’s over before you know it.
This wasn’t one of those jobs.
A bigass dude, and I don’t mean big boned (all though he was that too) but Large and In Charge, looking a little worried and breathing kinda heavy. Our guy’s sitting on his bed in what’s called tripod position, leaning forward with his hands on his knees, puffing in and out like he just spent 20 minutes underwater. Still, I’ve seen much worse and he’s not blue, not lethargic, not gasping. At this point, could be a anxiety attack, a mellow dramatic head cold or a bad breakup.
He’s only 34 but has an enlarged heart- damn near the size of my head, the x ray later reveals- and i literally coulda crawled into his belly and taken a nap it was so effin huge, probably from the excess fluid buildup from his backed up heart.
When your ventricles are that gigantoid, they don’t work right. Sometimes they work so asscrappily that the blood doesn’t fully make it out and stays backed up, which causes the bodywide puffiness. That’s when the right ventricle backs up. When the left one goes the fluid ends up in your lungs, and that’s when you start drowning in yourself.
Neither of this dude’s ventricles were working well. You could hear the excess blood lapping up against his lungwalls, a rising inner tide.

Jumped into action. Checked his ekg (predictably fast but otherwise ok), found a vein and put an IV in. Put some nitroglycerin under his tongue to open up those tightly clenched blood vessels, lower that pressure some and get the blood flowing. Got ready to move.
Now there’s something bout moving patients that completely fucks em up. Even a relatively stable patient that we’re literally lifting up to put on the chair and carrying the whole way, no exertion whatsoever, can still end up like 5 degrees more effed up by the time you get em on the ambulance. It’s just the stress of moving, being moved, I suppose, plus the sudden rush of cold air when they get outside never helps. But it’s something you count on, so especially when it’s a dude like this, you treat a little aggressive before you move just to pre-empt the inevitable decline.
The problem was, this dude was getting worse and worse even before we started moving him. His mild discomfort had blossomed into a full blown freak out, which was causing him to stress his already taxed heart even more. The fluid was rising steadily higher and higher with each passing moment. My partner and i were doing the everything’s cool routine, without lying to him about what ws going on mind you, I’m just sayin we weren’t panicked, but there was no mistaking how fast we were moving. Dude was agitated.
So we get em on the chair but when I tell you I was eyeing it to see if it’d give out…Anyway, the other problem was that he lived DOWNstairs, which meant we were gonna havta heave him UP ‘em to get out. Plus he was in some weird basement complex, so we had 2 wind our way through a weird atrium, back into a building, over cracks and bumps and through a little tunnel b4 reaching the stairwell. And lemme tell you: the only thing worse than lugging hugeness is lugging hugeness that is freaking the fuck out and about to code. By the Grace of God we got to the stairs and then I swear it was like some serious epic shit, every single step. I was on the top part, yelling in Spanish at the patient “Tranquilo, papa, ¡calmate coño!” and a cop had the bottom bar, and he was just lookn copconfused and sweating. We heavehoe’d each step, letting out some real Neanderthal-ass grunts and there was a couple times i really didn’t think it was gonna happen but it did and we loaded him up in the bus and reassessed.
He was still bad, flopping and flailing bad, but not quite as bad as he coulda been. We’d pushed lasix earlier, which drains you out and makes you haveta pee something mean, and a few more nitros were working their way thru his system. My guess was that he’d make it (he did). Hopped in front, came up on the radio to let the hospital know were coming and what we had, drove the fuck off in a blur of blasting sirens and flashing lights.